By becoming savvy about how the reimbursement game is played, radiology practices can improve their chances of financial viability, according to Douglas Smith, founder and president of Barrington Lakes Group, a healthcare consulting firm in Barrington, IL. Smith gave attendees at the Radiology Business Management Association (RBMA) meeting in San Francisco last month a framework for understanding reimbursement for 2008 and beyond, and offered suggestions on how radiology practices can cope.
"Know how the game is played, know the rules -- both official and unofficial -- and get involved," Smith said.
Not for amateurs
Before delivering its proposed budget to the Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid (CMS) has to develop its plan, taking into consideration factors such as Deficit Reduction Act (DRA) provisions, utilization reviews, State Children's Health Insurance Program (SCHIP) provisions, conversion factor and sustainable growth rate adjustments, Medicare Payment Advisory Commission (MedPAC) recommendations, and other legislative directives. CMS publishes its proposal in the Federal Register for comment, and when the comment period is over, releases its budget to HHS.
Once HHS has received CMS' contribution, the proposal is submitted to the president. The president's request goes through House and Senate Appropriations before being delivered to a joint House and Senate conference. If there's agreement, the budget goes as an appropriations bill to the president for signature into law. But budgets can get bogged down at any juncture.
"The federal budgeting process is not as simple as you would think," Smith said. "It's fraught with political intrigue, horse trading, regulatory mandates, economic and public policy, and all manner of influences. Dealing with the government is not for amateurs."
Elected officials often don't differentiate between different imaging entities -- radiologist-, corporate-, or referring physician-owned -- but focus instead on imaging's spike in the percentage of total medical services, Smith said.
"The radiology profession is not well understood in the halls of Congress," Smith said. "Many Congress people don't realize that overutilization is something that is done to radiologists, not something they do."
Policy makers have moved to clamp down on costs with legislation such as the DRA, assuming that the increased volume of imaging exams performed compensates for federal reimbursement reductions.
It doesn't, of course. But unless radiologists and administrators begin to educate governmental representatives, medical imaging will get more of the same in coming years, Smith said.
In the meantime, any action that seems like it will decrease unnecessary imaging use is becoming more and more attractive to the federal powers-that-be. Smith predicts that Medicare will put preauthorization protocols in place in the next year, along with more accreditation requirements. Anti-markup efforts are gaining momentum. Separate diagnostic imaging fee schedule and conversion factors may emerge, especially for MR, CT, and PET, and certain diagnostic imaging sites of service and ownership models (hospital inpatient, outpatient, outpatient clinics, independent diagnostic testing facilities [IDTFs], office imaging) could also begin to get separate treatment, he said.
And enforcing existing laws will take priority over making new ones, Smith said. Potential fallout is that IDTFs will likely be targeted for cost-cutting measures.
"I expect CMS to grow its rule-making power in the coming months, especially in respect to IDTFs, anti-markup rules, and coverage determinations and restrictions," he said. "All these efforts will be directed at reducing cost and utilization."
Monkey see, monkey do
Commercial payors tend to follow the government's lead, and the management of medical imaging is no exception. Smith predicts that, like Medicare, private insurers will step up their preauthorization programs, especially for CT, MR, PET, breast MR, and digital mammography. Commercial payors' coverage limitations will follow those of CMS (watch CTA, MRA, PET, digital mammography), and site of service payment differentials will flourish.
The strategy of the day? "'Take it or leave it,'" Smith said. "(Payors will) get someone to cave and the rest of the market will go down with them."
The Association for Quality Imaging (AQI), the American College of Radiology (ACR), the American Society of Radiologic Technologists (ASRT), and the RBMA have been working to educate governmental representatives on the cost and practice of radiology. But more can be done, especially in light of the experience and resources of the American Hospital Association, the American College of Cardiology, and other advocacy groups. Radiology staff -- from physicians and imaging center operators to teleradiology companies, suppliers, and billing companies -- need to get active to gain a voice in Congress, Smith said.
He encouraged RBMA attendees to craft their message and create visit plans for CMS and HHS policy makers and staff in Congressional committees such as the following:
- Joint Economic Committee
- House Committee on Ways and Means
- House Committee on Small Business
- House Budget Committee
- House Committee on Appropriations
- House Committee on Energy and Commerce
- Senate Special Committee on Aging
- Senate Committee on Health, Education, Labor, and Pensions
- Senate Budget Committee
- Senate Committee on Finance
- Senate Committee on Appropriations
"Paper these folks until it sticks," Smith said. "We need to educate Congress that diagnostic imaging is not a commodity."
Smith also encouraged attendees to consider ways to differentiate their practices from the competition to hospitals, medical staff, community leaders, business leaders, hospital boards, state medical societies, CMS carriers, commercial payors in the area, and the public.
"The answer to the question, 'Why you?' is not 'Quality' unless you can prove it with metrics," Smith said. "If you don't differentiate yourself constantly with your customer base, someone else will."
By Kate Madden Yee
AuntMinnie.com staff writer
March 4, 2008
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